- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $190.55 / $263.03 / $3,548.13
| Facility | | $190.55 | $263.03 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $128.82 / $302.00
| Professional | | $100.00 | $128.82 | $302.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $125.89 / $173.78 / $213.80
| Facility | | $125.89 | $173.78 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $3,311.31 / $6,025.60
| Professional | | $3,311.31 | $3,311.31 | $6,025.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $295.12 / $812.83 / $2,511.89
| Facility | | $295.12 | $812.83 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.67 / $39.81 / $60.26
| Professional | | $34.67 | $39.81 | $60.26 |